India

Photo: Hadynyah/istock

Introduction

India bears the largest burden of P. vivax malaria cases globally with over 3.6 million cases (48% of global P. vivax malaria cases) occurring in India. 52% of all malaria deaths outside of sub-Saharan Africa also occur in India, making the country strategically important for malaria elimination, particularly in the South-East Asian region.

Transmission

Close to 164 million people are at risk of malaria in India. 37% of malaria cases in the country are as a result of P. vivax infection. About 70 % of malaria cases in India occur in five states: Odisha (36%), Chhattisgarh (12%), Jharkhand (9%), Madhya Pradesh (9%) and Maharashtra (5%).

Although 86% of the population are at risk of malaria, 20% of people bear 80% of malaria and have thus been categorized as high risk.3 High risk populations dwell mainly in forest, hilly, tribal and conflict-affected areas. What is more, there is low community awareness on malaria prevention and control among the tribal population, which poses challenges for the reduction of malaria transmission.3

The two main malaria parasites in the country are P. falciparum and P. vivax, although incidences of malaria from P. ovale and P. malariae have also been reported in some areas of the country. P. vivax occurs mainly in the plains while P. falciparum is most prevalent in forested and peripheral areas.3

Source: World Malaria Report 2018

The disease is transmitted by nine Anopheline species, although six of these are primarily responsible for transmission (Anopheles culicifacies, Anopheles stephensi, Anopheles dirus, Anopheles fluviatilis, Anopheles minimus and Anopheles epiroticus).4

Maximum transmission of malaria takes place during the June to September monsoon season. From the October to December following the monsoon period, collection of rainwater in pits and puddles creates breeding grounds for mosquitoes which increases transmission.3

Milestones for malaria elimination

In 2016, the Government of India developed a National Framework for Malaria Elimination (2016-2030) and a National Strategic Plan (NSP, 2017-2022) with the aim to eliminate malaria in all Category 1 and 2 districts (low and medium transmission districts) by 2022 and to ensure that Category 3 districts (highest transmission districts) are covered by a pre-elimination and elimination programme within that same period.3 

The goals of the National Framework for Malaria Elimination (2016–2030) are:

  • Eliminate malaria (i.e. zero indigenous cases) throughout the entire country by 2030; and
  • Maintain malaria–free status in areas where malaria transmission has been interrupted, and prevent re-introduction of malaria.

These goals align with WHO’s Global Technical Strategy for Malaria 2016–2030 (GTS) and the Asia Pacific Leaders Malaria Alliance Malaria Elimination Roadmap.3

Source: World Malaria Report 2018

Surveillance

According to the government’s National Framework for Malaria Elimination (2016-2030), all entomological units in the country will be strengthened and made functional. Additional measures include the reinforcement of routine surveillance for reducing transmission in high transmission areas, and instituting case-based surveillance as a critical intervention for elimination areas.3

In 2017, a comparison of reported malaria cases from India’s National Vector-Borne Disease Control Programme (NVBDCP) in comparison to figures from the World Health Organization (WHO) indicated that the country’s surveillance mechanism detects just about eight per cent of cases. A comparison of reported suspected versus reported cases in the 2018 World Malaria Report indicates that the figure could be even lower and that that just about 1% of cases are reported. This reinforces the need for enhanced national surveillance systems.4 The Indian Council of Medical Research has also launched the 'Malaria Elimination Research Alliance (MERA) India'. This is a collection of partners working on malaria control.5

Source: World Malaria Report 2018

Treatment policy for P. vivax

P. vivax malaria is treated with Chloroquine and primaquine for 14 days. The dosage of primaquine for radical treatment of P. vivax is 0.25 mg/Kg (14 days).1

G6PD testing policy

G6PD testing before treatment with primaquine is not recommended in national treatment guidelines.1

G6PD deficiency prevalence

G6PD deficiency prevalence is generally low (<1%).6